From the Guidelines
Elevated alkaline phosphatase (ALP) in a patient with pancreatitis and prior cholecystectomy requires prompt evaluation for biliary obstruction, and I recommend obtaining an urgent MRCP or ERCP to assess for common bile duct stones, strictures, or other obstructive pathology. While awaiting these studies, obtain liver function tests including AST, ALT, bilirubin, and GGT to help differentiate between biliary, hepatic, or bone sources of elevated ALP 1. Consider abdominal ultrasound as an initial imaging study if not already performed. The most common cause in this clinical scenario is likely residual or recurrent common bile duct stones or post-cholecystectomy biliary stricture. Sphincter of Oddi dysfunction should also be considered. If biliary obstruction is confirmed, therapeutic ERCP with sphincterotomy and stone extraction or stent placement may be necessary. The worsening ALP is concerning because despite cholecystectomy, patients can develop recurrent biliary problems that can exacerbate pancreatitis and lead to complications like cholangitis if not addressed promptly. Supportive care for pancreatitis should continue with IV hydration, pain management, and nutritional support as appropriate.
Some key points to consider in the management of this patient include:
- The importance of promptly evaluating for biliary obstruction in the setting of worsening ALP and pancreatitis, as highlighted in the 2023 ACR Appropriateness Criteria for abnormal liver function tests 1
- The role of MRCP or ERCP in assessing for common bile duct stones, strictures, or other obstructive pathology, as recommended in the 2017 updated guideline on the management of common bile duct stones 1
- The need for supportive care for pancreatitis, including IV hydration, pain management, and nutritional support, as emphasized in the 2018 American Gastroenterological Association Institute guideline on initial management of acute pancreatitis 1
- The potential for recurrent biliary problems despite cholecystectomy, and the importance of considering Sphincter of Oddi dysfunction as a possible cause of worsening ALP, as noted in the 2007 AGA Institute medical position statement on acute pancreatitis 1
Overall, the management of this patient requires a comprehensive approach that takes into account the potential causes of worsening ALP, the need for prompt evaluation and treatment of biliary obstruction, and the importance of supportive care for pancreatitis.
From the Research
Worsening Alk Phos in the Setting of Pancreatitis and History of Cholecystectomy
- The worsening of alkaline phosphatase (alk phos) levels in a patient with a history of pancreatitis and cholecystectomy can be attributed to several factors, including the presence of gallstones or biliary sand in the bile ducts 2.
- Studies have shown that stones in the bile ducts can remain asymptomatic for long periods after cholecystectomy, but can trigger acute pancreatitis months or years later, causing a risk of mortality 2.
- The standard treatment for this condition is endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES), and if these are unsuccessful, the choledochus may be explored via open or laparoscopic surgery 2.
- Cholecystectomy has been proposed as a strategy to prevent recurrent idiopathic acute pancreatitis (IAP), and studies have shown that it can reduce the risk of recurrent pancreatitis 3.
- However, the optimal timing and technique of cholecystectomy in severe or necrotizing pancreatitis is unclear, and more research is needed to determine the best approach 4.
- The pathophysiology of alkaline phosphatase is complex, and defective elimination of the enzyme can play a major role in the pathogenesis of serum alkaline phosphatase elevations 5.
- A diagnostic workup for a patient with elevated serum alkaline phosphatase should include visualization of the biliary tree by cholangiography and evaluation of liver histology 6.
Possible Causes of Worsening Alk Phos
- Gallstones or biliary sand in the bile ducts 2
- Defective elimination of alkaline phosphatase 5
- Cholestasis due to a defect in bile synthesis, impairment in bile secretion, or obstruction to bile flow 6